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M. CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
KIMBERLEY DRISCOLL 120 WASHINGTON STREET,4"FLOOR
f MAYOR TEL.(978)741-1800
FAX(978)745-0343
LARRY RAMDIN,RS/REHS,CHO,CP-FS LRAMDINru'SALEM.COM
HEALTH AGENT
COMPLAINT INTAKE FORM
Date: Time: M:-5-IT
Received By:
Complaint Number: 1728
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Address: 1 r' Phone:
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Investigated By�- "]'� t, ; Date: JI�
Property Owner/Occupant Name Telephone #:
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